Portage County EMS Patient Care Guidelines Obstetrical Emergencies Note: • • • • • • This protocol is intended to cover obstetrical emergencies up to the point of active delivery (bleeding, pre-eclampsia/ eclampsia, ectopic pregnancy, spontaneous abortion, etc.). For emergencies related to active labor, refer to the Childbirth Guidelines. Consider that any unexplained abdominal complaints in a woman of child bearing age may be an obstetrical emergency Eclampsia occurs in pregnant patients with “preeclampsia”. Preeclampsia is a syndrome that involves hypertension [2] and output of protein in the urine. Eclampsia occurs when seizures and/or coma develop between the 20th week of pregnancy and the 4th week after delivery There is a significant associated risk of death for the mother and the baby. Maternal complications of eclampsia include: placental abruption, hemorrhagic stroke, pulmonary edema, cardiac arrest, and postpartum hemorrhage. Hypertension during pregnancy is defined by a systolic pressure over 140 mmHg and a diastolic pressure over 90 mmHg. Pregnancy usually lowers the blood pressure. A rise in the blood pressure after the 20th week of gestation is worrisome for preeclampsia. Eclampsia sometimes occurs even in women with blood pressures below 140/90 mmHg. Priorities Assessment Findings Chief Complaint “Abdominal pain”, “Vaginal bleeding”, “Cramping”, “Swelling”, ”Dizzyness”, “Visual changes”, “Gush of fluid from vagina” Symptom onset; due date, time contractions started & how often, location of their OB/GYN physician Headache, weakness, abdominal pain, vaginal bleeding/ discharge, Hypertension medications; number of prior pregnancies including this one (gravid) & number of deliveries (para); past delivery history (duration of labor, complications); pre-natal care; report of protein in the urine Check ABC’s and correct any immediate life threats Vitals: BP, HR, RR, Temp, SpO2 General Appearance: Altered level of consciousness, pale, diaphoretic? Anxiety? Signs of trauma? Edema of hands and face? Seizing or postictal? Incontinent (bowel, bladder)? HEENT: PERRL? Pupils constricted or dilated? Visual changes? Lungs: Rales? Wheezes? Heart: Rate and rhythm? Signs of hypoperfusion or hypertension? Neuro: Altered level of consciousness? Seizures? Dizzyness? Focal deficits? Vaginal Exam: Crowning, leaking fluids, bleeding Blood glucose, SpO2, ETCO2 Maintain ABC’s; terminate seizures; DO NOT attempt to treat maternal hypertension in the field. Cardiac monitoring, repeat vitals, capnography LOPQRST AS/PN AMPL Initial Exam Detailed Focused Exam Data Goals of Therapy Monitoring EMERGENCY MEDICAL RESPONDER/ EMERGENCY MEDICAL TECHNICIAN • Routine Medical Care 3/25/14 Obstetrical Emergencies Guideline Page 1 of 3 • • • If unconscious with a stable airway, pregnant patients should be placed in the recovery position on their left side Administer oxygen 2 – 4 LPM per nasal cannula if SpO2 < 94%. Increase flow and consider non-rebreather mask to keep SpO2 > 94% If vaginal bleeding, absorb bleeding with pads. Keep pads and any discharged tissue and transport to hospital with patient. Give a status report to the ambulance crew by radio ASAP. ADVANCED EMERGENCY MEDICAL TECHNICIAN • • • IV normal saline @ KVO If SBP < 100 mmHg, initiate a fluid bolus of 500 ml normal saline Consider a second IV for continued hypotension INTERMEDIATE • • • • • • • Notify Medical Control as soon as possible so that the receiving hospital can prepare for an emergent delivery Cardiac monitoring Magnesium sulfate is the medication of choice for eclamptic seizures. Consider a paramedic intercept If the patient is actively seizing, give midazolam[1] intranasal(IN) via mucosal atomizer. o >50 kg: 10 mg IN o <50 kg: 0.2 mg/kg IN If IN administration is not possible, consider midazolam 1 – 5 mg IM Once an IV has been established, consider midazolam 1 – 5 mg IV/IO for continued seizures Titrate IV dose to effect. May repeat once in 5 minutes. Maximum total dose 10 mg Contact Medical Control for the following: • Additional medication and airway management orders for continued seizures PARAMEDIC • For pre-ecclampsia/ ecclampsia (seizure activity or SBP > 160) administer magnesium sulfate (MgSO4) 4 grams IV/IO SLOW (over 10 min) o Monitor patient closely for hypotension, muscle weakness (including respiratory muscle paralysis), and heart rhythm disturbances Contact Medical Control for the following: • IM MgSO4 orders if unable to establish IV/IO • Additional medication and airway management orders for continued seizures FOOTNOTES: [1] In the event of a midazolam medication shortage: a. Lorazepam 1 – 2 mg adults IM/IN/IV/IO or b. Diazepam 1 – 5 mg adults IM/IV/IO. 3/25/14 Obstetrical Emergencies Guideline Page 2 of 3 Date of Origin: 3/25/14 Medical Director Approval: Date of This Revision: Electronically Signed Date of Review: Timothy Vayder, DO, FACOEP 3/25/14 Obstetrical Emergencies Guideline Page 3 of 3